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First Name

Last Name

Billing Address

Phone Number:

Email address:

How did you hear about me?

YouTube

Instagram

Clicked on Facebook Ad

I saw you in my Facebook Feed

Facebook business page

I participated in the Smoothies Gone Wild Challenge

Gut Healing Rituals Webinar

A friend or family member suggested I contact you

Doctor or other provider referral (please specify in other their name)

Google (please specify in OTHER below what you typed into Google ex: anti-inflammatory diet food sensitivities IBS diet etc.)

Other (please specify)

What is your number one top health/nutrition concern at this time? Why is this important to you?

What is your second health/nutrition concern at this time? Why is this important to you?

What is your third health/nutrition concern at this time? Why is this important to you?

What symptoms are you experiencing that effect your life, work, and relationships? Check all that apply. hold control/cmd to select multiple choices

For any other symptoms experienced but not included on this list, please describe.

On a scale of 1-10, how important is it for you to fix these problems right now? 1=Not important at all, 10=Very important

1

2

3

4

5

6

7

8

9

10

What will happen (share your deepest fears) if you do not get to the root cause and address your symptoms?

List all the diets, programs and or strategies you have tried to help address your symptoms?

What is the biggest thing that usually sabotages your efforts or keeps you stuck?

What are the outcomes that you would want to achieve in our work together?

If you could wave a magic wand, what would be improved with your health, nutrition and lifestyle? How do you imagine your life would be different?

Which type of support do you think would fit you best? check all that apply

My discovery breakthrough sessions are 90 minutes and an investment of $250. If we're a good fit, can you commit? HSA/FSA cards are accepted. If you need some time to be ready for this commitment, I recommend waiting to book this call until you're ready.

Yes- I can invest in the discovery session.

No- I'm not able to commit to this.

My programs are 3-6 months long and an investment of $997-$4,500. If we're a good fit after our discovery breakthrough session, can you commit? HSA/FSA cards are accepted.

Yes- I have the financial resources to invest in my health.

Yes- I have the ability to obtain the financial resources to invest in my health.

No- I do not have the financial resources to invest in my health.

It's likely I will recommend we get started right away. If we're a good fit, how soon can you get started?

ASAP!!

I'll need some time to prepare for the investment.

I'm not ready. Just curious about working with you.

Anything else you would like to add to your application?